Trends in Use and Adverse Outcomes Associated with Transvenous Lead Removal in the United States

Sex differences in long-term outcomes following transvenous lead extraction

INTRODUCTION

Transvenous lead extraction (TLE) is generally considered a safe procedure, albeit not without risks. While gender-based disparities have been noted in short-term outcomes following TLE, a notable gap exists in understanding the long-term consequences of this procedure. The objective of this analysis was to investigate sex differences in both acute and long-term outcomes among patients who underwent TLE at a tertiary referral center.

METHODS

In this retrospective cohort study, consecutive patients who underwent TLE between January 2014 and January 2016 were enrolled. The primary outcome comprised a composite of all-cause mortality and need for repeated TLE procedures. Secondary outcomes included fluoroscopy time, lead extraction techniques, success rates, and major and minor complications. Results were compared between female and male cohorts.

RESULTS

The study population comprised 191 patients (median age, 70 years), 29 (15.2%) being women and 162 men (84.8%). Study groups had similar baseline characteristics. Complete procedural success was achieved in 189 out of 191 patients (99.0%), with no significant difference observed between the two groups (p = .17). No major complications were reported in the total cohort. However, there was a significantly higher incidence of minor complications in women compared to men (17.2% vs. 2.5%, p < .01). Following a median follow-up of 6.5 years, the incidence of the primary composite outcome occurred similarly between the study groups (log-rank p = .68).

CONCLUSION

Women who underwent TLE exhibited a significantly higher incidence of minor acute intra- and peri-procedural complications than men. However, no differences in long-term outcomes between genders were observed.

Outcome and microbiological findings of patients with cardiac implantable electronic device infection

INTRODUCTION

Infections associated with cardiac implantable electronic devices (CIEDs) are a multifactorial disease that leads to increased morbidity and mortality.

OBJECTIVE

The aim was to analyze patient-, disease- and treatment-related characteristics including microbiological and bacterial spectrum according to survival status and to identify risk factors for 1- and 3-year mortality in patients with local and systemic CIED infection.

METHODS

In a retrospective cohort study, we analyzed data from patients with CIED-related local or systemic infection undergoing successful transvenous lead extraction (TLE). Survival status as well as incidence and cause of rehospitalization were recorded. Microbiology and antibiotics used as first-line therapy were compared according to mortality. Independent risk factors for 1- and 3-year mortality were determined.

RESULTS

Data from 243 Patients were analyzed. In-hospital mortality was 2.5%. Mortality rates at 30 days, 1- and 3 years were 4.1%, 18.1% and 30%, respectively. Seventy-four (30.5%) patients had systemic bacterial infection. Independent risk factors for 1-year mortality included age (OR 1.05 [1.01-1.10], p = 0.014), NT-proBNP at admission (OR 4.18 [1.81-9.65], p = 0.001), new onset or worsened tricuspid regurgitation after TLE (OR 6.04 [1.58-23.02], p = 0.009), and systemic infection (OR 2.76 [1.08-7.03], p = 0.034), whereas systemic infection was no longer an independent risk factor for 3-year mortality. Staphylococcus aureus was found in 18.1% of patients who survived and in 25% of those who died, p = 0.092. There was a high proportion of methicillin-resistant strains among coagulase-negative staphylococci (16.5%) compared to Staphylococcus aureus (1.2%).

CONCLUSIONS

Staphylococci are the most common causative germs of CIED-infection with coagulase-negative staphylococci showing higher resistance rates to antibiotics. The independent risk factors for increased long-term mortality could contribute to individual risk stratification and well-founded treatment decisions in clinical routine. Especially the role of tricuspid regurgitation as a complication after TLE should be investigated in future studies.

Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

Impact of infective versus sterile transvenous lead removal on 30-day outcomes in cardiac implantable electronic devices

BACKGROUND

Transvenous lead removal (TLR) is associated with increased mortality and morbidity. This study sought to evaluate the impact of TLR on in-hospital mortality and outcomes in patients with and without CIED infection.

METHODS

From January 1, 2017, to December 31, 2020, we utilized the nationally representative, all-payer, Nationwide Readmissions Database to assess patients who underwent TLR. We categorized TLR as indicated for infection, if the patient had a diagnosis of bacteremia, sepsis, or endocarditis during the initial admission. Conversely, if none of these conditions were present, TLR was considered sterile. The impact of infective vs sterile indications of TLR on mortality and major adverse events was studied.

RESULTS

Out of the total 25,144 patients who underwent TLR, 14,030 (55.8%) received TLR based on sterile indications, while 11,114 (44.2%) received TLR due to device infection, with 40.5% having systemic infection and 59.5% having isolated pocket infection. TLR due to infective indications was associated with a significant in-hospital mortality (5.59% vs 1.13%; OR = 5.16; 95% CI 4.33-6.16; p < 0.001). Moreover, when compared with sterile indications, TLR performed due to device infection was associated with a considerable risk of thromboembolic events including pulmonary embolism and stroke (OR = 3.80; 95% CI 3.23-4.47, p < 0.001). However, there was no significant difference in the conversion to open heart surgery (1.72% vs. 1.47%, p < 0.111), and infection was not an independent predictor of cardiac (OR = 1.12; 95% CI 0.97-1.29) or vascular complications (OR = 1.12; 95% CI 0.73-1.72) between the two groups.

CONCLUSION

Higher in-hospital mortality and rates of thromboembolic events associated with TLR resulting from infective indications may warrant further pursuing this diagnosis in patients.

Contemporary Management of Cardiac Implantable Electronic Device Infection: The American College of Cardiology COGNITO Survey

Background

Cardiac implantable electronic devices (CIEDs) infection remains a serious complication, causing increased morbidity and mortality. Early recognition and escalation to definitive therapy including extraction of the infected device often pose challenges.

Objectives

The purpose of this study was to assess U.S.-based physicians current practices in diagnosing and managing CIED infections and explore potential extraction barriers.

Methods

An observational survey was performed by the American College of Cardiology including U.S. physicians managing CIEDs from February to March 2022. Sampling techniques and screener questions determined eligibility. The survey featured questions on knowledge and experience with CIED infection patients and case scenarios.

Results

Of 387 physicians completing the survey (20% response rate), 49% indicated familiarity with current guidelines regarding CIED infection. Electrophysiologists (EPs) (91%) were more familiar with these guidelines, compared to non-EP cardiologists (29%) and primary care physicians (23%). Only 30% of physicians specified that their institution had guideline-based protocols in place for managing patients with CIED infection. When presented with pocket infection cases, approximately 89% of EPs and 50% of non-EP cardiologists would follow guideline recommendation to do complete CIED system removal, while 70% of primary care physicians did not recommend guideline-directed treatment.

Conclusions

There are gaps in familiarity of guidelines as well as the knowledge in practical management of CIED infection with non-extracting physicians. Most institutions lack a definite pathway. Addressing discrepancies, including guideline education and streamlining care or referral pathways, will be a key factor to bridging the gap and improving CIED infection patient outcomes.

Lead Extraction and Mortality Among Patients With Cardiac Implanted Electronic Device Infection

Importance

Complete hardware removal is a class I recommendation for cardiovascular implantable electronic device (CIED) infection, but practice patterns and outcomes remain unknown.

Objective

To quantify the number of Medicare patients with CIED infections who underwent implantation from 2006 to 2019 and lead extraction from 2007 to 2019 to analyze the outcomes in these patients in a nationwide clinical practice cohort.

Design, Setting, and Participants

This cohort study included fee-for-service Medicare Part D beneficiaries from January 1, 2006, to December 31, 2019, who had a de novo CIED implantation and a CIED infection more than 1 year after implantation. Data were analyzed from January 1, 2005, to December 31, 2019.

Exposure

A CIED infection, defined as (1) endocarditis or infection of a device implant and (2) documented antibiotic therapy.

Main Outcomes and Measures

The primary outcomes of interest were device infection, device extraction, and all-cause mortality. Time-varying multivariable Cox proportional hazards regression models were used to evaluate the association between extraction and survival.

Results

Among 1 065 549 patients (median age, 78.0 years [IQR, 72.0-84.0 years]; 50.9% male), mean (SD) follow-up was 4.6 (2.9) years after implantation. There were 11 304 patients (1.1%) with CIED infection (median age, 75.0 years [IQR, 67.0-82.0 years]); 60.1% were male, and 7724 (68.3%) had diabetes. A total of 2102 patients with CIED infection (18.6%) underwent extraction within 30 days of diagnosis. Infection occurred a mean (SD) of 3.7 (2.4) years after implantation, and 1-year survival was 68.3%. There was evidence of highly selective treatment, as most patients did not have extraction within 30 days of diagnosed infection (9202 [81.4%]), while 1511 (13.4%) had extraction within 6 days of diagnosis and 591 (5.2%) had extraction between days 7 and 30. Any extraction was associated with lower mortality compared with no extraction (adjusted hazard ratio [AHR], 0.82; 95% CI, 0.74-0.90; P < .001). Extraction within 6 days was associated with even lower risk of mortality (AHR, 0.69; 95% CI, 0.61-0.78; P < .001).

Conclusions and Relevance

In this study, a minority of patients with CIED infection underwent extraction. Extraction was associated with a lower risk of death compared with no extraction. The findings suggest a need to improve adherence to guideline-directed care among patients with CIED infection.

Transvenous lead extraction: Efficacy and safety of the procedure in female patients

Background

Existing data on the impact of sex differences on transvenous lead extraction (TLE) outcomes in cardiac device patients are limited.

Objective

The purpose of this study was to evaluate the safety and efficacy of mechanical TLE in female patients.

Methods

A retrospective evaluation was performed on 3051 TLE patients (group 1: female; group 2: male) from a single tertiary referral center. All individuals received treatment using single sheath mechanical dilation and various venous approaches as required.

Results

Our analysis included 3051 patients (group 1: 750; group 2: 2301), with a total of 5515 leads handled with removal. Female patients were younger, had a higher left ventricular ejection fraction, and lower prevalences of coronary artery disease and diabetes mellitus. Infection was more common in male patients, whereas lead malfunction or abandonment were more frequent in female patients. Radiologic success was lower in female patients (95.8% vs 97.5%; P = .003), but there was no significant difference in clinical success between groups (97.2% vs 97.5%; P = .872). However, major complications (1.33% vs 0.60%; P <.001) and procedural mortality (0.4% vs 0.1%; P <.001) were higher in females compared to male patients. After multivariate analysis, female sex emerged as the only predictor of major complications, including deaths (odds ratio 3.96; 95% confidence interval 1.39-11.24).

Conclusion

TLE using unpowered simple mechanical sheaths in female patients is safe and effective, but is associated with lower radiologic success and higher complication rates and mortality than in males. This finding underscores the importance of recognizing sex differences in TLE outcomes.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Transvenous lead extraction in children with bidirectional rotational dissection sheaths

Objectives

Due to the limited longevity of endovascular leads, children require thoughtful lifetime lead management strategies including conservation of access vessel patency. Consequently, there is an increasing interest in transvenous lead extraction (TLE) in children, however, data on TLE and the use of powered mechanical dissection sheaths is limited.

Methods

We performed a retrospective cohort study analyzing all children <18 years that underwent TLE in our institution from 2015 to 2022. Procedural complexity, results and complications were defined as recommended by recent consensus statements.

Results

Twenty-eight children [median age 12.8 (interquartile range 11.3-14.6) years] were included. Forty-one leads were extracted [median dwell time 85 (interquartile range 52-102) months]. Extractions of 31 leads (76%) in 22 patients (79%) were complex, requiring advanced extraction tools including powered bidirectional rotational dissection sheaths in 14 children. There were no major complications. Complete procedural success was achieved in 18 (64%) and clinical success in 27 patients (96%), respectively. Procedural success and complexity varied between lead types. The Medtronic SelectSecure™ lead was associated with increased odds of extraction by simple traction (p = 0.006) and complete procedural success (p < 0.001) while the Boston Scientific Fineline™ II lead family had increased odds of partial procedural failure (p = 0.017).

Conclusions

TLE with the use of mechanical powered rotational dissection sheaths is feasible and safe in pediatric patients. In light of rare complications and excellent overall clinical success, TLE should be considered an important cornerstone in lifetime lead management in children. Particular lead types might be more challenging and less successful to extract.

Sex differences in outcomes of transvenous lead extraction: insights from National Readmission Database

BACKGROUND

With the growing use of implantable cardiac devices, the need for transvenous lead extraction has increased, which translates to increased procedural volumes. Sex differences in lead extraction outcomes are not well studied.

OBJECTIVE

The present study aims at evaluating the impact of sex on outcomes of lead extraction.

METHODS

We identified 71,754 patients who presented between 2016 and 2019 and underwent transvenous lead extraction. Their clinical data were retrospectively accrued from the National Readmission Database (NRD) using the corresponding diagnosis codes. We compared clinical outcomes between male and female patients. Odds ratios (ORs) for the primary and secondary outcomes were calculated, and multivariable regression analysis was utilized to adjust for confounding variables.

RESULTS

Compared to male patients, female patients had higher in-hospital complications including pneumothorax (OR 1.26, 95% CI (1.07-1.4), P < 0.01), hemopericardium (OR 1.39, 95% CI (1.02-1.88), P = 0.036), injury to superior vena cava and innominate vein requiring repair (OR 1.88, 95% CI (1.14-3.1), P = 0.014; OR 3.4, 95% CI (1.8-6.5), P < 0.01), need for blood transfusion (OR 1.28, 95% CI (1.18-1.38), P < 0.01), and pericardiocentesis (OR 1.6, 95% CI (1.3-2), P < 0.01). Thirty-day readmission was also significantly higher in female patients (OR 1.09, 95% CI (1.02-1.17), P < 0.01). There was no significant difference regarding in-hospital mortality (OR 0.99, 95% CI (0.87-1.14), P = 0.95).

CONCLUSION

In female patients, lead extraction is associated with worse clinical outcomes and higher 30-day readmission rate.

Transvenous Lead Extraction during Cardiac Implantable Device Upgrade: Results from the Multicenter Swiss Lead Extraction Registry

BACKGROUND

Device patients may require upgrade interventions from simpler to more complex cardiac implantable electronic devices. Prior to upgrading interventions, clinicians need to balance the risks and benefits of transvenous lead extraction (TLE), additional lead implantation or lead abandonment. However, evidence on procedural outcomes of TLE at the time of device upgrade is scarce.

METHODS

This is a post hoc analysis of the investigator-initiated multicenter Swiss TLE registry. The objectives were to assess patient and procedural factors influencing TLE outcomes at the time of device upgrades.

RESULTS

941 patients were included, whereof 83 (8.8%) had TLE due to a device upgrade. Rotational mechanical sheaths were more often used in upgraded patients (59% vs. 42.7%, p = 0.015) and total median procedure time was longer in these patients (160 min vs. 105 min, p < 0.001). Clinical success rates of upgraded patients compared to those who received TLE due to other reasons were not different (97.6% vs. 93.0%, p = 0.569). Moreover, multivariable analysis showed that upgrade procedures were not associated with a greater risk for complications (HR 0.48, 95% confidence interval 0.14-1.57, p = 0.224; intraprocedural complication rate of upgraded patients 7.2% vs. 5.5%). Intraprocedural complications of upgraded patients were mostly associated with the implantation and not the extraction procedure (67% vs. 33% of complications).

CONCLUSIONS

TLE during device upgrade is effective and does not attribute a disproportionate risk to the upgrade procedure.

Long-term survival following transvenous lead extraction: unpicking differences according to sex

AIMS

Female sex is a recognized risk factor for procedure-related major complications including in-hospital mortality following transvenous lead extraction (TLE). Long-term outcomes following TLE stratified by sex are unclear. The purpose of this study was to evaluate factors influencing long-term survival in patients undergoing TLE according to sex.

METHODS AND RESULTS

Clinical data from consecutive patients undergoing TLE in the reference centre between 2000 and 2019 were prospectively collected. The total cohort was divided into groups based on sex. We evaluated the association of demographic, clinical, device-related, and procedure-related factors on long-term mortality. A total of 1151 patients were included, with mean 66-month follow-up and mortality of 34.2% (n = 392). The majority of patients were male (n = 834, 72.4%) and 312 (37.4%) died. Males were more likely to die on follow-up [hazard ratio (HR) = 1.58 (1.23-2.02), P < 0.001]. Males had a higher mean age at explant (66.2 ± 13.9 vs. 61.3 ± 16.3 years, P < 0.001), greater mean co-morbidity burden (2.14 vs. 1.27, P < 0.001), and lower mean left ventricular ejection fraction (LVEF) (43.4 ± 14.0 vs. 50.8 ± 12.7, P = 0.001). For the female cohort, age > 75 years [HR = 3.45 (1.99-5.96), P < 0.001], estimated glomerular filtration rate < 60 [HR = 1.80 (1.03-3.11), P = 0.037], increasing co-morbidities (HR = 1.29 (1.06-1.56), P = 0.011), and LVEF per percentage increase [HR = 0.97 (0.95-0.99), P = 0.005] were all significant factors predicting mortality. The same factors influenced mortality in the male cohort; however, the HRs were lower.

CONCLUSION

Female patients undergoing TLE have more favourable long-term outcomes than males with lower long-term mortality. Similar factors influenced mortality in both groups.

Cardiac device-related infective endocarditis need for lead extraction whatever the device according to the ESC EORP EURO-ENDO registry

Aims

Cardiac device-related infective endocarditis (CDRIE) is a severe complication of cardiac device (CD) implantation and is usually treated by antibiotic therapy and percutaneous device extraction. Few studies report the management and prognosis of CDRIE in real life. In particular, the rate of device extraction in clinical practice and the management of patients with left heart infective endocarditis (LHIE) and an apparently non-infected CD (LHIE+CDRIE-) are not well described.

Methods and results

We sought to study in EURO-ENDO, the characteristics, prognosis, and management of 483 patients with a CD included in the European Society of Cardiology EurObservational Research Programme EURO-ENDO registry. Three populations were compared: 280 isolated CDRIE (66.7 ± 14.3 years), 157 patients with LHIE and an apparently non-infected CD (LHIE+CDRIE-) (71.1 ± 13.6), and 46 patients with both LHIE and CDRIE (LHIE+CDRIE+) (70.2 ± 10.1). Echocardiography was not always transoesophageal echography (TOE); it was transthoracic echography (TTE) for isolated CDRIE in 88.4% (TOE = 67.6%), for LHIE+CDRIE- TTE = 93.0% (TOE = 58.6%), and for CDRIE+LHIE+ TTE = 87.0% (TOE = 63.0%). Nuclear imaging was performed in 135 patients (positive for 75.6%). In-hospital mortality was lower in isolated CDRIE 13.2% vs. 22.3% and 30.4% for LHIE+CDRIE- and LHIE+CDRIE+ (P = 0004). Device extraction was performed in 62.1% patients with isolated CDRIE, 10.2% of LHIE+CDRIE- patients, and 45.7% of CDRIE+LHIE+ patients. Device extraction was associated with a better prognosis [hazard ratio 0.59 (0.40-0.87), P = 0.0068] even in the LHIE+CDRIE- group (P = 0.047).

Conclusion

Prognosis of endocarditis in patients with a CD remains poor, particularly in the presence of an associated LHIE. Although recommended by guidelines, device extraction is not always performed. Device removal was associated with better prognosis, even in the LHIE+CDRIE- group.

Subcutaneous implantable cardioverter-defibrillator noise following left ventricular assist device implantation

Background

The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S-ICD) after left ventricular assist device (LVAD) implantation is not well established.

Methods

We performed a retrospective study of patients implanted with LVAD and with a pre-existing S-ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida).

Results

Of the 908 LVAD patients, a pre-existing S-ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third-generation EMBLEM MRI S-ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD-related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S-ICD sensing vector, adjusting S-ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S-ICD device therapies to be turned off permanently.

Conclusions

The incidence of LVAD-related S-ICD noise is high in patients with concomitant LVAD and S-ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S-ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD-SICD device interference and the need to improve S-ICD detection algorithms to eliminate noise.

Predictors for adverse events during cardiac lead extraction - Experience from a large single centre

BACKGROUND

As the use of cardiac implantable electronic devices (CIED) has increased in recent years, the need for transvenous lead extraction (TLE) has also steadily increased. However, the TLE procedure could lead to serious complications and even death. Clinical decision-making tools are necessary for predicting these adverse events, but the appropriate tools have not yet been developed.

OBJECTIVE

To explore the possible predictors and develop a clinical model to predict TLE related adverse events.

METHODS

All the patients who were admitted to our cardiac center for TLE from January 2014 to January 2021 were included in this study. The patient information, device baseline characteristics, procedure-related information, complications and outcomes were recorded. Independent predictors of TLE related adverse events were identified by univariate, LASSO and multivariate analysis. A nomogram for predicting these adverse events was developed based on these independent predictors. Calibration and decision curve analysis were conducted to evaluate the nomogram.

RESULTS

One thousand and one hundred patients were included in this study, 778 (70.7%) were male and the median age was 68 years old. A total of 2,208 leads were extracted and 2.01±0.74 leads were extracted per procedure. Fifty-five patients (5%) developed adverse events including minor complications (2.4%), major complications (2.3%) and death (0.27%). Seven independent predictors for TLE related adverse events were identified and selected to establish the nomogram including BMI, female gender, hypoalbuminemia, number of extracted leads>3, longest dwell time of the extracted leads and manual traction. The area under the receiver operating characteristic (ROC) curve (AUC) for the prediction model was 0.774. Calibration curve and decision curve analysis showed that the nomogram had good prediction performance.

CONCLUSION

TLE related adverse events are some of the key issues that concern clinicians. We have identified seven independent factors and established a predictive model that may help clinicians identify at-risk patients and create better plans for lead extraction.

Transvenous lead extractions in a single high-volume center over 24 years: High success rate and low complication rate

Background

Transvenous lead extraction (TLE) procedures can be complicated and are associated with a small but significant risk of cardiovascular complications. However, methods and tools vary among centers.

Objective

The purpose of this study was to the present the methods and results of pacemaker and implantable cardioverter-defibrillator TLE procedures in our center over a 24-year period.

Methods

From April 1997 through 2020, we attempted to extract 2964 leads in 1780 procedures and 1642 patients. We mainly utilized single sheath technique using snaring or mechanical rotational sheaths and steel sheaths when necessary. Difficult procedures were performed by an experienced cardiologist, and close supervision was emphasized. Most of the extractions were performed using local anesthesia with sedation.

Results

Median age of patients was 65.0 [interquartile range 20.00] years, and median dwelling time of leads was 5.0 [7.0] years. Clinical success was achieved in 1739 procedures (97.7%) and complete technical success in 2841 leads (95.8%). Clinical success (leaving <4 cm of the lead in the body and achieving the clinical goal for the patient) was achieved for 79 leads (2.7%). TLE failed in 44 leads (1.1%) and 41 procedures (2.3%) among 36 patients (2.2%). There were 23 cases (1.3%) of major complications, with only 1 death directly related to the procedure (<0.1%). In addition, 2 patients with sepsis died within the first 24 hours after the procedure. No caval tears occurred.

Conclusion

Single sheath lead extractions utilizing snaring or mechanical rotational sheaths were effective and safe in our high-volume center as performed by experienced operators.

Causes of Early Mortality After Transvenous Lead Removal

BACKGROUND

Recognition of the causes of early mortality (≤30 days) after transvenous lead removal (TLR) is an essential step for the development of quality improvement programs.

OBJECTIVES

This study sought to determine the causes of early mortality after TLR and to further understand the circumstances surrounding death after TLR.

METHODS

A retrospective analysis was performed of all patients undergoing TLR from January 1, 2001, to January 1, 2021, at the Mayo Clinic (Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida). Causes of death were identified through a detailed chart review of the electronic health record from within the Mayo Clinic system and outside records when available. The causes of death were further characterized based on whether it was related to the TLR procedure.

RESULTS

A total of 2,319 patients were included in the study. The overall 30-day all-cause mortality rate was 3% (n = 69). Among all 30-day deaths, infection was the most common primary cause of death (42%). This was followed by decompensated heart failure (17%), procedure-related death (10%), sudden cardiac arrest (7%), and respiratory failure (6%). The 30-day mortality rate directly due to complications associated with the TLR procedure was 0.3%. One-third of deaths (33%) occurred after discharge from the index hospitalization; among these, 43% were readmitted before their death, 35% died at home or at a nursing facility, and 22% were discharged on comfort care and died in hospice. The main reasons for readmission before death were sepsis and decompensated heart failure.

CONCLUSIONS

The majority (90%) of 30-day mortality after TLR was not due to complications associated with TLR procedures. The primary causes were infection and decompensated heart failure. This highlights the importance of increased emphasis on postprocedure management of infection and heart failure to reduce postoperative mortality, including after hospital discharge.

Successful Avoidance of Superior Vena Cava Injury During Transvenous Lead Extraction Utilizing Tandem Femoral-Superior Approach

BACKGROUND

Transvenous pacemaker and defibrillator lead extraction is a higher risk procedure with variation in preferred technique. A frequently fatal complication of this procedure is perforation of the superior vena cava. We have developed a tandem femoral-superior technique which incorporates snaring of targeted leads from a femoral approach combined with use of a rotational cutting sheath advanced over the lead from the subclavian vein.

OBJECTIVE

We sought to evaluate the safety and efficacy of a tandem femoral-superior approach to lead extraction.

METHODS

Consecutive patients undergoing transvenous extraction of at least 1 pacemaker or defibrillator lead with implant duration >1 year in which a tandem femoral-superior technique was used as the initial extraction strategy were included. The registry spanned 2010-2018 and consisted of procedures performed by a single primary operator.

RESULTS

A total of 131 patients were included. A total of 267 leads with mean implant duration of 9.8 years, including 90 (33.7%) defibrillator leads, were targeted for extraction. No superior vena cava perforation or other vascular damage occurred. Clinical procedural success was achieved in 96.2 % of cases. There were 5 major complications (3.8% of patients) with 3 being pericardial effusion requiring intervention. There were no deaths.

CONCLUSION

A tandem femoral-superior approach to lead extraction effectively eliminated superior vena cava injury. This is a safe and effective technique for transvenous lead extraction.

Arrhythmias in Female Patients: Incidence, Presentation and Management

There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.

Impact of Timing of Transvenous Lead Removal on Outcomes in Infected Cardiac Implantable Electronic Devices

BACKGROUND

Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality and morbidity.

OBJECTIVE

This study sought to evaluate the impact of early versus delayed transvenous lead removal (TLR) on in-hospital mortality and outcomes in patients with CIED infection.

METHODS

Using the nationally representative, all-payer, Nationwide Readmissions Database, we evaluated patients undergoing TLR for CIED infection between January 1, 2016, to December 31, 2018. The timing of the TLR procedure was determined based on hospitalization days after initial admission for CIED infection. The impact of early (≤ 7 days) versus delayed (> 7 days) TLR on mortality and major adverse events was studied.

RESULTS

Of 12,999 patients who underwent TLR for CIED infections, 8,834 patients underwent early TLR versus 4,165 patients who underwent delayed TLR. Delayed TLR was associated with a significant increase in in-hospital mortality (8.3% vs. 3.5%, adjusted odds ratio:1.70; 95% confidence interval, 1.43-2.03; P value<0.001). Subgroup analysis of patients with CIED infection and systemic infection showed that delayed TLR in patients with systemic infection was associated with a higher rate of in-hospital mortality compared with early TLR (10.4% vs. 7.5%, adjusted odds ratio:1.24; 95% confidence interval, 1.04-1.49; P value<0.019). Delayed TLR was also associated with significantly higher adjusted odds of major adverse events and post-procedural length of stay.

CONCLUSIONS

These data suggest that delayed transvenous lead removal in patients with CIED infections is associated with increased in-hospital mortality and major adverse events, especially in patients with systemic infection.

Safety and feasibility of trans-venous cardiac device extraction using conscious sedation alone-Implications for the post-COVID-19 era

BACKGROUND

Transvenous lead extraction (TLE) for implantable cardiac-devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID-19, longer recovery-times and increased procedural-costs. We report the feasibility/safety of TLE using conscious-sedation alone with immediate GA/cardiac-surgery back-up if needed.

METHODS

Retrospective case-series of consecutive TLEs performed using conscious-sedation alone between March 2016 and December 2019. All were performed in the electrophysiology-laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking-stylets/cutting-sheaths, including mechanical-sheaths. Baseline patient-characteristics, procedural-details and TLE outcomes (including procedure-related complications/death) were recorded.

RESULTS

A total of 130 leads were targeted in 54 patients, mean age ± SD 74.6 ± 11.8years, 47(87%) males; dual-chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy-defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean ± SD/median (range) lead-dwell times were 11.0 ± 8.8/8.3 (0.3-37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse-generator erosion (n = 27; 50%); mean 2.1 ± 2.0 leads were removed per procedure/mean procedure-time was 100 ± 54 min. Local anesthetic (LA) was used for all (mean-dose: 33 ± 8 ml 1% lidocaine), IV drug-doses used (mean ± SD) were: midazolam: 3.95 ± 2.44 mg, diazepam: 4.69 ± 0.89 mg and fentanyl: 57 ± 40 µg. Complete lead-extraction was achieved in 110 (85%) leads, partial lead-extraction (<4 cm-fragment remaining) in 5 (4%) leads. Sedation-related hypotension requiring IV fluids occurred in 2 (managed without adverse-consequences) and hypoxia requiring additional airway-management in none. No procedural deaths occurred, one patient required emergency cardiac surgery for localized ventricular perforation, nine had minor complications (transient hypotension/bradycardia/pericardial effusion not requiring intervention).

CONCLUSION

TLE undertaken using LA/conscious-sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolization of COVID-19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.

Transvenous lead extraction using the TightRail mechanical rotating dilator sheath for Asian patients

The need for transvenous lead extraction (TLE) is increasing worldwide including in Asia–Pacific regions. However, supporting evidence for TightRail, a relatively new rotating mechanical dilator sheath, is still lacking in Asian patients. The efficacy and safety of TLE using TightRail performed between March 2018 and June 2021 were evaluated in 86 consecutive patients with 131 leads. The mean lead age was 11.7 ± 7.3 (range, 1.0–41.4) years. Clinical and complete procedural success using TightRail were achieved in 93.0% and 89.5% of 86 patients, respectively, with 6 min of median fluoroscopic time and 9.3% of major complication rate: death (1.2%), cardiac tamponade (3.5%), severe tricuspid regurgitation (3.5%), and stroke (1.2%). However, in 46 patients with longest lead age ≤ 10 years, clinical/complete success and major cardiac complication rates turned out better as 97.8%, 95.7%, and 2.2%, respectively. Additionally, when patients were divided into 3 groups: the first 28, second 29, and the last 29 patients, there was a clear trend toward better efficacy and safety outcomes with more experience with TightRail (P_trend < 0.05). Longest lead age > 10 years was closely associated with TLE-related major cardiac complication (P = 0.046) with 85.7% sensitivity, 57.0% specificity, 15.0% positive predictive value, and 97.8% negative predictive values. In conclusion, TLE using TightRail may be effectively and safely performed by experienced operators for Asian patients with the longest lead age ≤ 10 years. However, as TightRail is a potentially aggressive tool, special attention should be paid to patients with longer lead dwelling times (e.g., > 10 years).

Epidemiology and Outcomes of Hospitalizations Due to Hepatocellular Carcinoma

Background Hepatocellular Carcinoma (HCC) is a severe complication of cirrhosis and the incidence of HCC has been increasing in the United States (US). We aim to describe the trends, characteristics, and outcomes of hospitalizations due to HCC across the last decade. Methods We derived a study cohort from the Nationwide Inpatient Sample (NIS) for the years 2008-2017. Adult hospitalizations due to HCC were identified using the International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM). Comorbidities were also identified by ICD-9/10-CM codes and Elixhauser Comorbidity Software (Agency for Healthcare Research and Quality, Rockville, Maryland, US). Our primary outcomes were in-hospital mortality and discharge to the facility. We then utilized the Cochran-Armitage trend test and multivariable survey logistic regression models to analyze the trends, outcomes, and predictors. Results A total of 155,436 adult hospitalizations occurred due to HCC from 2008-2017. The number of hospitalizations with HCC decreased from 16,754 in 2008 to 14,715 in 2017. Additionally, trends of in-hospital mortality declined over the study period but discharge to facilities remained stable. Furthermore, in multivariable regression analysis, predictors of increased mortality in HCC patients were advanced age (OR 1.1; 95%CI 1.0-1.2; p< 0.0001), African American (OR 1.3; 95%CI 1.1-1.4;p< 0.001), Rural/ non-teaching hospitals (OR 2.7; 95%CI 2.4-3.3; p< 0.001), uninsured (OR 1.9; CI 1.6-2.2; p< 0.0001) and complications like septicemia and pneumonia as well as comorbidities such as hypertension, diabetes mellitus, and renal failure. We observed similar trends in discharge to facilities. Conclusions In this nationally representative study, we observed a decrease in hospitalizations of patients with HCC along with in-hospital mortality; however, discharge to facilities remained stable over the last decade. We also identified multiple predictors significantly associated with increased mortality, some of which are potentially modifiable and can be points of interest for future studies.

The Use of Transvenous Lead Extraction of Non-Infected Leads to Prevent Long-Term Lead-Related Complications

The aim of the investigation was to study the issue of making challenging decisions concerning abandonment or removal of non-infected superfluous leads during lead revisions or cardiac implantable electronic device upgrades.

Strategies to increase the INGEVITY lead strength during lead extraction procedures based on laboratory bench testing

Background

The INGEVITY lead (Boston Scientific, St Paul, MN, USA) has excellent clinical performance. However, its single filar design results in decreased lead tensile strength and a possible challenging extraction. This study's goal is to evaluate techniques for extracting the INGEVITY lead.

Methods

Two‐ and three‐dimensional models were created to simulate lead extraction from a right atrial appendage lead implant with a left subclavian approach and lead/fibrosis attachment sites. Standard and unique lead extraction preparation strategies were evaluated. Traction forces were measured from a superior approach alone or in combination with a femoral approach.

Results

For lead extraction via the superior approach, leaving the terminal on the lead was the only factor influencing maximum tolerated load (p‐value = .0007). Scar attachment provided greater lead tensile strength by transferring traction loading forces to the polyurethane outer insulation but dependent on insulation integrity. The strongest extraction rail was seen with a simulated femoral snaring of a locking stylet within the INGEVITY lead. Deployed screw retraction was most successful by rotating a Philips LLD#2 stylet (Philips Healthcare, Amsterdam, Netherlands) within the lead.

Conclusion

Results from in vitro simulations of INGEVITY lead extraction from an atrial location found the lead has low maximum tensile strength resulting in a poor extraction rail with common extraction tools and methods. However, the strength of the INGEVITY Lead extraction rail can be significantly increased by leaving the lead terminal intact and femoral snaring of the locking stylet within the lead. Such techniques may improve extraction of the INGEVITY lead.

Knowledge gaps, lack of confidence, and system barriers to guideline implementation among European physicians managing patients with CIED lead or infection complications: a European Heart Rhythm Association/European Society of Cardiology educational needs assessment survey

As the number of patients with cardiac implantable electronic devices (CIEDs) grows, they are likely to present with issues to diverse groups of physicians. Guideline-adherent management is associated with improved prognosis in patients with CIED infection or lead problems but is insufficiently implemented in practice. The European Heart Rhythm Association (EHRA) with the support of the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery, performed a multinational educational needs assessment study in ESC member countries, directed at physicians who might be confronted with CIED patients with complications. A total of 336 physicians from 43 countries, reached through the ESC mailing list, participated. They included a mix of electrophysiologists, cardiologists general physicians and cardiac surgeons .One hundred and twenty-nine (38%) of the respondents performed lead extraction. The survey included eight clinical cases and a self-evaluation question of knowledge and skills to apply that knowledge. The survey looked at 14 areas of care across five stages of the patient journey. Of the non-extracting physicians over 50% felt they lacked the knowledge and skills to make the diagnosis and refer for lead extraction and over 75% felt they lacked knowledge and skills to manage aspects of extraction and post-extraction care. Barriers to correct referral were logistic and attitudinal. Extracting physicians reported significantly higher rates of adequate skills and knowledge across all five stages of the patient journey (P < 0.05). We identified major gaps in physicians' knowledge and skills across all stages of CIED care. These gaps should be addressed by targeted educational activities and streamlining referral pathways.

The emergence of Staphylococcus aureus as the primary cause of cardiac device-related infective endocarditis

BACKGROUND

Increasing use of cardiovascular implantable electronic devices (CIED), as permanent pacemakers (PPM), implantable cardioverter defibrillators (ICD), or cardiac resynchronization therapy (CRT), is associated with the emergence of CIED-related infective endocarditis (CIED-IE). We aimed to characterize CIED-IE profile, temporal trends, and prognostic factors.

METHODS

CIED-IE diagnosed at Rennes University Hospital during years 1992-2017 were identified through computerized database, and included if they presented all of the following: (1) clinical signs of infection; (2) microbiological documentation through blood and/or CIED lead cultures; (3) lead or valve vegetation, or definite IE according to Duke criteria. Data were retrospectively extracted from medical charts. The cohort was categorized in three periods: 1992-1999, 2000-2008, and 2009-2017.

RESULTS

We included 199 patients (51 women, 148 men, median age 73 years [interquartile range, 64-79]), with CIED-IE: 158 PPMs (79%), 24 ICD (12%), and 17 CRT (9%). Main pathogens were coagulase-negative staphylococci (CoNS: n = 86, 43%), Staphylococcus aureus (n = 60, 30%), and other Gram-positive cocci (n = 28, 14%). Temporal trends were remarkable for the decline in CoNS (P = 0.002), and the emergence of S. aureus as the primary cause of CIED-IE (24/63 in 2009-2017, 38%). Factors independently associated with one-year mortality were chronic obstructive pulmonary disease (COPD: hazard ratio 3.84 [1.03-6.02], P = 0.03), left-sided endocarditis (HR 2.25 [1.09-4.65], P = 0.03), pathogens other than CoNS (HR 3.16 [1.19-8.39], P = 0.02), and CIED removal/reimplantation (HR 0.41 [0.20-0.83], P = 0.01).

CONCLUSIONS

S. aureus has emerged as the primary cause of CIED-IE. Left-sided endocarditis, COPD, pathogens other than CoNS, and no CIED removal/reimplantation are independent risk factors for one-year mortality.

Outcomes of transvenous lead extraction using the TightRail™ mechanical rotating dilator sheath and excimer laser sheath

BACKGROUND

Transvenous lead extraction (TLE) is an important part of comprehensive lead management. The selection of tools available has expanded in recent years but data on their efficacy is limited.

OBJECTIVE

To evaluate outcomes using the TightRail™ mechanical rotating mechanical dilator sheath in comparison to excimer laser sheaths and describe factors predictive of successful extraction.

METHODS

Patients undergoing TLE at a single tertiary center (2013-2019) were included in a prospective registry. Leads targeted for extraction with either an SLS II/Glidelight™ or TightRail™ sheath were included. Outcomes were analyzed on a per-lead basis. Generalized estimating equation (GEE) models were used to assess differences in lead extraction success by extraction tool used while adjusting for nonindependence of multiple leads extracted from the same patient. Covariates included patient comorbidities, lead characteristics, and sheath size.

RESULTS

A total of 575 leads extracted from 372 patients were included. Overall success rate was 97%. TightRail™ was the first tool used in 180 (31.3%) leads with success rate of 61.7%; laser sheaths were the first tool in 395 leads (68.7%) with success rate of 67.8%. Predictors of successful extraction included lead age, lead type, and sheath sizing. Extraction success did not differ based on whether a laser or TightRail™ sheath was used (adjusted odds ratio = 0.94; 95% confidence interval = 0.59-1.50).

CONCLUSION

The TightRail™ sheath is an effective tool for TLE. Lead age, lead type, and sheath sizing were predictive of successful extraction but sheath type was not. These findings are hypothesis generating and warrant further investigation in a prospective, randomized study.

Magnetic Resonance Imaging in Patients With Cardiac Implantable Electronic Devices With Abandoned Leads

Importance

Magnetic resonance imaging (MRI) is the modality of choice for many conditions. Conditional devices and novel protocols for imaging patients with legacy cardiac implantable electronic devices (CIEDs) have increased access to MRI in patients with devices. However, the presence of abandoned leads remains an absolute contraindication.

Objective

To assess if the performance of an MRI in the presence of an abandoned CIED lead is safe and whether there are deleterious effects on concomitant active CIED leads.

Design, Setting, and Participants

This cohort study included consecutive CIED recipients undergoing 1.5-T MRI with at least 1 abandoned lead between January 2013 and June 2020. MRI scans were performed at the Hospital of the University of Pennsylvania. No patients were excluded.

Exposures

CIEDs were reprogrammed based on patient-specific pacing needs. Electrocardiography telemetry and pulse oximetry were monitored continuously, and live contact with the patient throughout the scan via visual and voice contact was performed if possible. After completion of the MRI, CIED evaluation was repeated and programming returned to baseline or to a clinically appropriate setting.

Main Outcomes and Measures

Variation in pre- and post-MRI capture threshold of 50% or more, ventricular sensing 40% or more, and lead impedance 30% or more, as well as clinical sequelae such as pain and sustained tachyarrhythmia were considered significant. Long-term follow-up lead-related data were analyzed if available.

Results

A total of 139 consecutive patients (110 men [79%]) with a mean (SD) age of 65.6 (13.4) years underwent 200 MRIs of various anatomic regions including the thorax. Repeat examinations were common with a maximum of 16 examinations for 1 patient. There was a total of 243 abandoned leads with a mean (SD) of 1.22 (0.45) per patient. The mean (SD) number of active leads was 2.04 (0.78) and 64 patients (46%) were pacemaker dependent. A transmit-receive radiofrequency coil was used in 41 patients (20.5%), all undergoing MRI of the brain. There were no abnormal vital signs or sustained tachyarrhythmias. No changes in battery voltage, power-on reset events, or changes of pacing rate were noted. CIED parameter changes including decreased right atrial sensing in 4 patients and decreased left ventricular R-wave amplitude in 1 patient were transiently noted. One patient with an abandoned subcutaneous array experienced sternal heating that subsided on premature cessation of the study.

Conclusions and Relevance

The risk of MRI in patients with abandoned CIED leads was low in this large observational study, including patients who underwent examination of the thorax. The growing aggregate of data questions the absolute contraindication for MRI in patients with abandoned CIED leads.

Endovascular occlusion balloon-related thrombosis during transvenous lead extraction

AIMS

The aim of this study is to evaluate the incidence, predictors, and outcomes of balloon-related thrombosis (BRT) in patients undergoing transvenous lead extraction (TLE). Use of an endovascular occlusion balloon has improved outcomes of superior vena cava injuries during TLE. Its thrombogenicity in clinical practice is unknown.

METHODS AND RESULTS

We prospectively evaluated consecutive patients undergoing prophylactic balloon placement during TLE utilizing two procedural workflows: one with the balloon within the inferior vena cava during the entire case (standard cohort) and one limiting the balloon's dwell time (abbreviated cohort). Intracardiac echocardiography was used to evaluate for significant BRT (thrombus > 1 cm) after TLE. Forty-two patients (21 in each group) were included. Age, left ventricular ejection fraction, procedural indication, number of leads, and lead dwell time were similar between the groups. Balloon dwell time was significantly longer in the standard group (128 ± 74 vs. 25 ± 18 min, P < 0.001) as was BRT (14/21 vs. 1/21, P < 0.001). Mean thrombus length and width in the standard group was 3.99 ± 1.40 and 0.45 ± 0.16 cm, respectively and 5.2 × 0.4 cm in one patient in the abbreviated group. Between patients with and without BRT in the standard group, balloon dwell times were similar (113 ± 64 vs. 156 ± 88 min, P = 0.21). One patient in the standard group had a pulmonary embolism on post-operative Day 3 and was initiated on oral anticoagulation.

CONCLUSION

Prophylactic balloon placement for the entirety of the case is associated with a high incidence of BRT; a finding that is decreased when an abbreviated workflow is utilized.

Transvenous lead extraction in 1000 patients guided by intraprocedural risk stratification without surgical backup

BACKGROUND

Transvenous lead extraction (TLE) carries a significant risk of morbidity and mortality. Reliable preprocedural risk predictors to guide resource allocation and optimize procedural safety are lacking.

OBJECTIVE

The aim of this study was to evaluate an intraprocedural approach to risk stratification during elective TLE procedures.

METHODS

This is a single-center retrospective study of consecutive patients who underwent elective TLE of a pacemaker or implantable cardioverter-defibrillator lead for noninfectious indications. The risk of TLE is judged intraprocedurally only after an attempt is made to extract the target lead as long as high-risk extraction techniques are avoided. TLE was performed in a well-equipped electrophysiology laboratory with rescue strategies in place but in the absence of surgical staff.

RESULTS

During the study period, 1000 patients were included in this analysis (527 female (52.7%); mean age 61.5 ± 10.2 years). TLE was attempted for 1362 leads, with a mean lead dwell time of 73 ± 43 months (median 70 months; interquartile range 12-180 months). TLE was successful in 914 patients, partially successful in 10, and failed in 76 patients. A laser sheath was required for extraction of 926 leads (68%). Only 1 patient developed intraprocedural cardiac tamponade requiring emergency pericardiocentesis. None of the patients developed hemothorax or required surgical intervention.

CONCLUSION

At experienced centers, intraprocedural risk stratification for TLE that avoids high-risk extraction techniques achieved successful TLE in the majority of patients and can potentially help optimize the balance between efficacy, safety, and efficiency in lead extraction.

Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction

BACKGROUND

There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction.

OBJECTIVE

To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE).

METHODS

Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23).

RESULTS

During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed.

CONCLUSION

Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Effectiveness and Safety of Transvenous Removal of Cardiac Pacing and Implantable Cardioverter-defibrillator Leads in the Real Clinical Scenario

Fundamento

Remoção de cabos-eletrodos de dispositivos cardíacos eletrônicos implantáveis (DCEI) é procedimento pouco frequente e sua realização exige longo treinamento profissional e infraestrutura adequada.

Objetivos

Avaliar a efetividade e a segurança da remoção de cabos-eletrodos de DCEI e determinar fatores de risco para complicações cirúrgicas e mortalidade em 30 dias.

Métodos

Estudo prospectivo com dados derivados da prática clínica. De janeiro/2014 a abril/2020, foram incluídos, consecutivamente, 365 pacientes submetidos à remoção de cabos-eletrodos, independentemente da indicação e técnica cirúrgica utilizada. Os desfechos primários foram: taxa de sucesso do procedimento, taxa combinada de complicações maiores e morte intraoperatória. Os desfechos secundários foram: fatores de risco para complicações intraoperatórias maiores e morte em 30 dias. Empregou-se análise univariada e multivariada, com nível de significância de 5%.

Resultados

A taxa de sucesso do procedimento foi de 96,7%, sendo 90,1% de sucesso completo e 6,6% de sucesso clínico. Complicações maiores intraoperatórias ocorreram em 15 (4,1%) pacientes. Fatores preditores de complicações maiores foram: tempo de implante dos cabos-eletrodos ≥ 7 anos (OR= 3,78, p= 0,046) e mudança de estratégia cirúrgica (OR= 5,30, p= 0,023). Classe funcional III-IV (OR= 6,98, p<0,001), insuficiência renal (OR= 5,75, p=0,001), infecção no DCEI (OR= 13,30, p<0,001), número de procedimentos realizados (OR= 77,32, p<0,001) e complicações maiores intraoperatórias (OR= 38,84, p<0,001) foram fatores preditores para mortalidade em 30 dias.

Conclusões

Os resultados desse estudo, que é o maior registro prospectivo de remoção de cabos-eletrodos da América Latina, confirmam a segurança e a efetividade desse procedimento no cenário da prática clínica real. (Arq Bras Cardiol. 2020; 115(6):1114-1124)

Erosion of Cardiovascular Implantable Device: Conservative Therapy or Extraction?

The standard of care for device infection is normally a complete removal of the implantable system, including lead extraction in local or systemic infection cases. Despite the importance of lead extraction techniques, these techniques are complex and have some major risks. Success rates were high, but they are less favorable in patients with several comorbidities. An 80-year-old male presented for device erosion. The patient is known to have several cardiac comorbidities: a transcatheter aortic valve replacement (TAVR), mitral clips for severe aortic stenosis, mitral regurgitation, dual-chamber implantable cardioverter defibrillators (ICD) for secondary prevention. Several weeks ago, he noted tenderness and redness at the site of his device pocket, and his physician, after checking his wound, suggested a possible skin irritation with no systemic infection and started antibiotics treatment. Two weeks later, he noted thinning of the skin around the device with a hematoma and ecchymosis, and slight skin erosion. Strategies for assessment of the wound and pocket cleaning were taken. The strategy was to remove the left-sided device and keep the leads since the patient lately has no elevated inflammatory labs, negative cultures, no fever, nor signs of vegetation on transesophageal echocardiography (TEE) and refused any additional examination as positron emission tomography (PET) scan, and reimplant a new system on the contralateral side. The procedure was divided into two sequences: extracting the device and after one-week implantation of a right-sided new system. In this case, chronic antibiotics were discussable to decrease the recurrence rate, but they did increase the severity of the patient's thrombocytopenia. Despite extraction being the gold standard of treatment in most cases of devices with local and systemic infection, there are some frail patients with several comorbidities where extraction is unbearable due to its major risks and complex procedure. In these specific cases with local infection and device erosion with no signs of any systemic infection, conservative therapy could be a viable option.

Safety of transvenous lead removal in adult congenital heart disease: a national perspective

INTRODUCTION AND OBJECTIVES

Data are scarce on outcomes of transvenous lead removal (TLR) in adult congenital heart disease (CHD). We evaluated the safety of the TLR procedure in adult CHD patients from a 10-year national database.

METHODS

We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify TLR procedures in adult patients with and without CHD from 2005 to 2014. Outcomes included in-hospital mortality and complications.

RESULTS

Of 132 068 adult patients undergoing TLR, 1939 had simple CHD, 657 had complex CHD, and 626 had unclassified CHD. The number of TLR procedures in adult CHD slightly increased from 236 in 2005 to 445 in 2014, with fluctuations over the study period. The overall rate of any complications in the TLR procedure was 16.6% in patients with CHD vs 10.1% in patients without CHD (P <.001). In a propensity score-matched cohort, CHD was associated with a higher risk of any complication after full adjustment vs patients without CHD (adjusted odd ratio, 1.49; 95% confidence interval, 1.11-1.99; P=.007). Simple and complex CHD were associated with 1.5- and 2.1-fold increased risks of any TLR-related complication, respectively. CHD was not associated with an increased risk of in-hospital mortality (adjusted odd ratio, 0.77; 95% confidence interval, 0.42-1.39; P=.386).

CONCLUSIONS

Compared with patients without CHD, adult patients with simple and complex CHD undergoing TLR are more likely to have complications but show no increase in mortality.

[Infections in interventional electrophysiology]

The implantation of pacemakers and defibrillators carries the highest risk of infection in interventional electrophysiology. The use of implantable cardiac devices is continually increasing with almost 2 million devices implanted worldwide each year. The recipients' profile may also be associated with an increased risk of infection. Several measures can be implemented to reduce the risk of device-related infection. Systematic antibiotic prophylaxis has proven to be beneficial provided that prescription modalities are respected, especially with respect to the selection of the appropriate molecule and timing of administration prior to the procedure. Despite all the precautions taken during surgery (asepsis, prophylactic antibiotic therapy….) the estimated rate of peri-procedural infection is around 2%. Device related infections are associated with a high rate of morbidity and mortality as well as substantial healthcare costs. Staphylococcus aureus (SA) and epidermidis (SE) are the pathogenic agents involved in most cases. Prevention is crucial given the difficulties in treating such infections because of the near-systematic need to remove the device and antibiotic resistance. Leadless pacemakers and subcutaneous defibrillators are potential alternatives to implantable endocardial devices, albeit with certain limitations. A group of experts has recently issued consensus paper on the prevention, diagnosis and treatment of infections associated with endocardial implantable cardiac devices.

Major cardiac and vascular complications after transvenous lead extraction: acute outcome and predictive factors from the ESC-EHRA ELECTRa (European Lead Extraction ConTRolled) registry

AIMS

We aimed at describing outcomes and predictors of cardiac avulsion or tear (CA/T) with tamponade and vascular avulsion or tear (VA/T) after transvenous lead extraction (TLE) in the ESC-EHRA European Lead Extraction ConTRolled (ELECTRa) registry.

METHODS AND RESULTS

A total of 3555 consecutive patients of whom 3510 underwent TLE at 73 centres in 19 European countries were enrolled. Among 58 patients (1.7%) with procedure-related major complications, 49 (84.5%) patients (30 CA/T and 19 VA/T) presented cardiovascular complications requiring pericardiocentesis, chest tube positioning and/or surgical repair. The mortality was 20% in patients with tamponade due to CA/T and 31.6% in patients with VA/T. Pericardiocentesis as first manoeuvre followed by rescue surgical repair was highly effective in case of CA/T (93.8%). At multivariate analysis, CA/T with tamponade was more common in RIATA lead extraction, female patients, leads with a mean dwelling time more than 10 years, and when ≥3 leads were extracted or multiple sheaths required. Occlusion or critical stenosis of superior venous access and the leads mean dwelling time more than 10 years were independent predictors for VA/T, while mechanical dilatation was an independent predictor of a lower incidence of this complication as compared to the use of powered sheaths.

CONCLUSIONS

In the ELECTRa registry, RIATA lead extraction and superior venous access occlusion/thrombosis are two new independent predictors for cardiac tamponade and major vascular complications, respectively. The use of mechanical sheaths seems to be associated with a lower incidence of VA/T. A strategy of pericardiocentesis followed by a rescue surgical approach seems to be reasonable in order to treat a CA/T with tamponade.

Study Design of the Nationwide Japanese Lead Extraction (J-LEX) Registry: Protocol for a Prospective, Multicenter, Open Registry

BACKGROUND

Transvenous lead extractions (TLEs) in Japan have grown to become the standard therapy since the approval of the laser extraction system in 2008. However, little is known about the current indications, methods, success rate, and acute complications in the real-world setting.

METHODS

The Japanese Lead EXtraction (J-LEX) registry is a nationwide, multicenter, observational registry, performed by the Japanese Heart Rhythm Society (JHRS) in collaboration with the National Cerebral and Cardiovascular Center. This study is a nationwide registry ordered by the JHRS and its data are collected prospectively using the Research Electronic Data Capture (REDCap) system. The acute success rate at discharge and complications associated with TLEs will be collected in all cases. Based on the provided information, the annual incidence and predictive factors for the outcomes will be investigated by the Event Assessment Committee (EAC). This registry started in July 2018 and the number of participating medical institutions will be more than 50 hospitals and the target number of procedures will be 500-1000 per year. We will also compare the results with other registries in foreign countries.

RESULT

The results of this study are currently under investigation.

CONCLUSION

The J-LEX registry will provide real-world data regarding the results and complications of TLEs for the various types of indications, methods, and performing hospitals in Japan.

Safety and Efficacy of Cardiovascular Implantable Electronic Device Extraction in Elderly Patients: A Meta-Analysis and Systematic Review

Background

Transvenous lead extraction of cardiovascular implantable electronic device (CIED) has been proven safe in the general patient population with the advances in extraction techniques. Octogenarians present a unique challenge given their comorbidities and the perceived increase in morbidity and mortality.

Objective

To assess the safety and outcomes of CIED extraction in octogenarians to younger patients.

Methods

We performed an extensive literature search and systematic review of studies that compared CIED extraction in octogenarians versus non-octogenarians. We separately assessed the rate of complete procedure success, clinical success, procedural mortality, major and minor complications. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used due to heterogeneity across study cohorts.

Results

Seven studies with a total of 4,182 patients were included. There was no difference between octogenarians and non-octogenarians in complete procedure success (RR 1.01, 95% CI 1.00 - 1.02, p = 0.19) and clinical success (RR 1.01, 95% CI 1.00 - 1.01, p = 0.13). There was also no difference in procedural mortality (RR 1.43, 95% CI 0.46 - 4.39, p = 0.54), major complication (RR 1.40, 95% CI 0.68 - 2.88, p = 0.36), and minor complication (RR 1.43, 95% CI 0.90 - 2.29, p = 0.13).

Conclusion

In this study, there was no evidence to suggest a difference in procedural success and complication rates between octogenarians and younger patients. Transvenous lead extraction can be performed safely and effectively in the elderly population.

Diagnosis and management of subcutaneous implantable cardioverter-defibrillator infections based on process mapping

BACKGROUND

Infection is a well-recognized complication of cardiovascular implantable electronic device (CIED) implantation, including the more recently available subcutaneous implantable cardioverter-defibrillator (S-ICD). Although the AHA/ACC/HRS guidelines include recommendations for S-ICD use, currently there are no clinical trial data that address the diagnosis and management of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics.

METHODS

A process mapping methodology was used to achieve a primary goal - the development of consensus on the diagnosis and management of S-ICD infections. Two face-to-face meetings of panel experts were conducted to recommend useful information to clinicians in individual patient management of S-ICD infections.

RESULTS

Panel consensus of a stepwise approach in the diagnosis and management was developed to provide guidance in individual patient management.

CONCLUSION

Achieving expert panel consensus by process mapping methodology in S-ICD infection diagnosis and management was attainable, and the results should be helpful in individual patient management.

Outcomes of cardiac implantable electronic device transvenous lead extractions performed in centers without onsite cardiac surgery

BACKGROUND

While major complications associated with CIED lead extractions are uncommon, they carry a significant risk of morbidity and mortality in the absence of surgical intervention. However, there is limited data on the differences in outcomes of these procedures between centers with and without on-site CS support. The present study examined outcomes of transvenous cardiac implantable electronic device (CIED) lead extractions according to admitting hospitals' cardiac surgery (CS) facilities.

METHODS

We analyzed the National Inpatient Sample for CIED lead extraction procedures, stratified by hospitals' CS facilities into two groups; on-site and off-site CS. Logistic regression analyses were performed to estimate the adjusted odds (aOR) of procedure-related complications in off-site CS centers.

RESULTS

In 221,606 procedures over an 11-year-period, CIED lead extractions were increasingly undertaken in on-site as opposed to off-site CS centers (Onsite CS 2004 vs. 2014: 78.2% vs. 90.4%, p < 0.001) during the study period. In comparison to on-site CS group, patients admitted to off-site CS group were older, less comorbid, and experienced lower adjusted odds of major adverse cardiovascular events (0.72 [0.67, 0.77]), mortality (0.60 [0.52, 0.69]), procedure-related bleeding (0.48 [0.44, 0.54]) and complications (thoracic: 0.81 [0.75, 0.88]; cardiac: 0.45 [0.38, 0.54]) (p < 0.001 for all).

CONCLUSIONS

Our national analysis demonstrates that transvenous CIED lead extractions are being increasingly undertaken in centers with on-site CS surgery, in compliance with international guideline recommendations. Patients managed with lead extractions in on-site CS centers are more comorbid and critically ill compared to those admitted to off-site CS centers, and remain at a higher risk of procedure-related complications.